Trauma in Pregnancy · 2020. 5. 26. · Trauma in Pregnancy Jeffrey Sakamoto, MDa, Collin Michels,...

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Trauma in Pregnancy

Jeffrey Sakamoto, MDa, Collin Michels, MDa, Bryn Eisfelder, MDa,
Nikita Joshi, MDb,*
KEYWORDS

� Trauma in pregnancy � Blunt trauma � Penetrating trauma

KEY POINTS

� Trauma in pregnancy is challenging because there are two patients to consider duringresuscitation. It may not be clear based on history or physical that a patient is pregnant,and the physician should assess for pregnancy in patients of child-bearing age.

� Prioritization of maternal resuscitation is important to ensure optimal outcome for motherand fetus, which includes proceeding with medications and radiology examinationsbecause they are indicated without delay.

� Trauma management in pregnancy requires coordination between multiple specialtiesincluding emergency medicine, trauma surgery, obstetrics, and neonatology.

� Pregnant trauma patients often require prolonged observation in labor and delivery unitsafter initial stabilization in the emergency department. This may require transfer to anotherfacility for higher level of care.

INTRODUCTION

Although pregnant trauma patients present infrequently to the emergency department(ED), it is one of the most common contributors to maternal and fetal morbidity andmortality.1–8 Up to 1.5% of women admitted for traumatic injuries are pregnant4; how-ever, immediate recognition of pregnancy is not always possible, especially in cases offirst-trimester pregnancy, morbid obesity, or in critically injured patients. Additional tothe rarity of presentation and complicated pathophysiology, there is the cognitive loadof resuscitating two patients, mother and fetus; working with multiple specialtiesincluding trauma, obstetrics, and neonatology; and processing emotional and socialissues that can arise. Furthermore, the clinical course is difficult to predict becauseof a lack of correlation between the degree of trauma and clinical outcome.2 Uniquechallenges in pregnant trauma patients are listed in Box 1.

Disclosure Statement: None of the authors have any relationship with a commercial companythat has a direct financial interest in subject matter or materials discussed in article or with acompany making a competing product. The authors acknowledge the contribution of Dr Kim-berly S. Harney, Clinical Professor, Obstetrics, Stanford University, to this article.a Department of Emergency Medicine, Stanford University, 900 Welch Road, Suite 350, PaloAlto, CA 94304, USA; b Alameda Health Systems, 490 Grand Avenue, Oakland, CA 94610, USA* Corresponding author.E-mail address: [email protected]

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Box 1

Unique challenges in pregnant trauma patients

Complex physiologic adaptations of the pregnant patient throughout pregnancy

Need for multidisciplinary approach with multiple specialties

Mitigation of exposure to radiation and other teratogens

Management of pregnancy-specific related condition (ie, Rhesus factor isoimmunization,placental abruption)

Management of two patients concurrently

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BACKGROUND AND EPIDEMIOLOGY

Trauma has been found to be the leading nonobstetric cause of maternal death duringpregnancy, and is associated with up to 20% of maternal deaths in the UnitedStates.1,9 Traumatic injuries are estimated to complicate up to 1 in 12 pregnancies.2–4

In 2017, a study involving 1148 pregnant trauma patients found that pregnant womenhad significantly higher mortality compared with nonpregnant women, with a relativerisk (RR) of 1.6.1

Risk factors commonly associated with trauma in pregnancy include1,2,4,9:

� Age less than 26 years� African-American or Hispanic ethnicity� Medicaid insurance� Lower socioeconomic status� Minimal or no prenatal care in the first trimester

Risk stratification and identification of potential maternal and fetal complications arealso difficult. Even minor injuries as evaluated by the Injury Severity Score,10 a vali-dated tool in predicting mortality in nonpregnant populations,11,12 is not predictiveof fetal morbidity and mortality, and can still be associated with adverse pregnancyoutcomes.2,8

Mechanism of Injury

Unintentional or nonviolent trauma accounts for the largest portion of trauma in preg-nancy, including motor vehicle accidents (MVAs) and falls.8 Intentional or violenttrauma accounts for approximately 16% of traumatic injuries in pregnant women,and includes suicide, gunshot wounds, stab wounds, sexual assault, strangulation,and domestic violent (DV). Blunt trauma including MVAs and falls accounts for 88%to 92% of injuries, penetrating trauma including gun shot wounds (GSWs) and stabwounds account for approximately 2% to 7%, and burn injuries up to 4%. Althoughmost traumas are nonviolent in cause, pregnant patients are nearly twice as likely toexperience violent trauma compared with nonpregnant patients with increased mor-tality and a RR of 3.14.1,2,13–17

ANATOMY AND PHYSIOLOGY OF PREGNANT PATIENTS

As seen in Fig. 1, the uterus remains within the pelvis until approximately12 weeks gestational age (GA), reaching the umbilicus by 20 weeks GA, and the costalmargins by 34 weeks GA.18 By the end of the third trimester, the uterus size signifi-cantly alters anatomic location and function of abdominal and pelvic structures.Tables 1 and 2 summarize pertinent anatomic and physiologic changes as it relates

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Fig. 1. Approximate location of uterine fundus at different gestational ages.

Trauma in Pregnancy 319

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to trauma management.18–24 Understanding the clinical impact of these changes isimportant because it affects symptoms and manifestations of traumatic injuries.

Cardiovascular Changes

Cardiovascular adaptations allow for optimal oxygen (O2) delivery to maternal andfetal tissues. Plasma volume begins to expand by 6 to 8 weeks GA, increasing cardiacoutput up to 45%.6,18,21,24 Blood pressure decreases throughout pregnancy withaverage diastolic blood pressure decrement of 10 to 15 mm Hg, and average systolicblood pressure decrement of 5 to 10 mm Hg.19 After 20 weeks GA, the uterus rises tothe level of the inferior vena cava (IVC), causing compression of the IVC in the supineposition, decreasing cardiac preload and cardiac output by 10% to 30%.20,21 Thechanges can cause difficulty in identification of maternal hemorrhagic shock with upto 30% to 35% of circulating blood volume (almost 2000 mL) lost before exhibiting hy-potension. Increased blood flow to the uterus and injuries is a significant source ofhemorrhage. There may also be marked venous congestion throughout the pelvisand lower extremities increasing the risk of retroperitoneal hemorrhage with pelvicinjuries.18,22,25

Pulmonary Changes

Respiratory changes to optimize fetal oxygenation lead to 40% increase (approxi-mately 200 mL) in tidal volume leading to increased minute ventilation26 and lowerarterial PaCO2 (mean value of 30 mm Hg in pregnancy). The diaphragm rises up to4 cm during pregnancy, resulting in perceived penetrating chest trauma to actuallybe intra-abdominal.27


Table 1Anatomic changes in pregnancy

Structure Change Clinical Significance

Airway Edema and friability Difficult intubation

Uterus Extends beyond bonypelvis after firsttrimester

Direct uterine injury

Gravid uterus>20 wk GA

Supine hypotensionsecondary to IVCcompression

Bladder Moves anteriorlyand superiorlyinto abdomenin third trimester

Direct bladder injury

Physiologic bladderand uretercompression

Incorrect identificationof renal obstruction,when hydronephrosisand hydroureter canbe physiologic inpregnancy

Diaphragm Elevates superiorly4 cm

Pneumothorax, tensionpneumothorax requiringhigher thoracostomytube placement2–3 interspaces superiorly

Small bowel Higher displacementinto abdomen

Direct small bowelinjury withpenetratingtrauma to upperabdomen

Peritoneum Abdominal wallstretches aspregnancyprogresses

Underestimation ofintra-abdominalbleeding or organinjury because ofblunted response toperitoneal irritation

Ligaments ofPS and SI joints

Loosening Incorrect identificationof pelvic disruptionon radiograph becauseof baseline diastasis

Abbreviations: IVC, inferior vena cava; PS, pubic symphysis; SI, sacroiliac.

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Renal Changes

By 26 weeks GA, the renal plasma blood flow and glomerular filtration rate increaseresulting in decreased serum levels of creatinine and blood urea nitrogen.26 Renalexcretion of bicarbonate compensates for respiratory alkalosis resulting in decreasedlevels of serum sodium bicarbonate to 19 to 20 mEq/L.26 The bladder may be dis-placed anteriorly and superiorly, causing susceptibility to injury.22 Physiologic hydro-nephrosis and hydroureter may be seen on radiology imaging.21,24

Gastrointestinal Changes

Progesterone mediates delays in gastric emptying, decreased intestinal motility, anddecreased lower esophageal sphincter tone, which increases the risk of aspira-tion.22,23 Early gastric decompression should be considered in gravid women greater


Table 2Physiologic changes in pregnancy

System Physiologic Change Clinical Significance

Airway

Pulm Airway edema Difficulty airway, may requiresmaller ETT (6.0 and 6.5) andadditional airway adjuncts

[ O2 consumption, Y RV,and Y FRC

Requires preoxygenation withhigh flow O2 before induction

GI Y Gastric emptying, Y LES tone [ Risk of aspiration

Breathing

Pulm [ TV and [ MV Compensated respiratoryalkalosis, maintain EtCO230–35 mm Hg

Elevation of diaphragm Place chest tubes 1–2 intercostalspaces above fifth interspace

Circulation

CV [ Plasma volume Delayed recognition ofhemorrhagic shock with large-volume blood loss; physiologicanemia

[ HR and Y BP Vital signs poor marker ofhemodynamic stability

[ Uterine and bladderblood flow

[ Risk of maternal hemorrhagewith direct injury

[ Vascular congestion [ Risk of retroperitonealhemorrhage or lower extremitybrisk bleed

Miscellaneous

Renal [ rPBF, [ GFR, and Y Serum Cr Caution with drugs excretedthrough renal system

[ Bicarb excretion Y HCO3 on ABG (19–20 mEq/L),increased susceptibility toacidosis

Heme [ Fibrinogen, [ D dimer, Y PT, PTT,Y PLTs

Propensity to develop DIC

Abbreviations: ABG, arterial blood gas; BP, blood pressure; Cr, creatinine; CV, cardiovascular; DIC,disseminated intravascular coagulation, ETT, endotracheal tube; FRC, functional residual capacity;GFR, glomerular filtration rate; GI, gastrointestinal; HR, heart rate; LES, lower esophagealsphincter; MV, minute ventilation; PT, prothrombin time; PLT, platelet; PTT, partial thromboplastintime; Pulm, pulmonary; rPBF, renal plasma blood flow; RV, residual volume; TV, tidal volume.


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than 16 weeks GA with altered mental status, especially if undergoing intubation.18

The most common cause of abdominal hemorrhage is secondary to splenic injury.22

Hematopoietic Changes

Beyond the increase in plasma volume, other hematopoietic changes that graduallyoccur are summarized in Table 3.18,21,23,24 These alterations make it challenging todetect hemorrhage and shock.

ANATOMY AND PHYSIOLOGY OF FETUS

Fetal O2 requirements lead to increased blood flow to the uterus at the end of the thirdtrimester. Uterine blood flow is directly proportional to maternal mean arterial


Table 3Summary of hematopoietic differences in pregnancy

LaboratoryStudies (Units)

NonpregnantWomen Range

Pregnant Women

Change Range

Hemoglobin (g/dL) 12–15.8 Y 9–11

Hematocrit (%) 36–47 Y 31–35

White blood cell count (�103/mm3) 3.5–9.1 [ 14–16a

Platelets (�109/L) 250b Y 213b

Fibrinogen (mg/dL) 256b [ 473b

Factor VII (%) 99.3b [ 181.4b

Factor X (%) 97.7b [ 144.5b

a Peak of 25 during labor.b Mean value.

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pressure, and inversely proportional to the resistance of the uterine vasculature.20,22

This makes uteroplacental perfusion sensitive to decrease in maternal blood pressureduring resuscitation and maternal hemorrhage.25 The placenta creates a large, inelas-tic, and vascular conduit through which mother and fetus can exsanguinate duringplacental abruption without obvious external signs. In the event of uterine lacerationor rupture, rapid maternal exsanguination with significant impact to the fetus canoccur.24 Fetal hemoglobin and relative acidemia compared with mother causes slightpreservation of fetal oxygenation regardless of maternal PaO2 levels.

22 However, thesefactors are not fully protective during prolonged maternal hypoxia.18,20,22

MATERNAL TRAUMA RESUSCITATION

As with nonpregnant patients, the trauma evaluation of a pregnant patient starts withairway, breathing, and circulation. All women should be considered pregnant untilproven otherwise, because it was found that 3% of women admitted to a trauma cen-ter were pregnant and of those, 11% were incidental findings.28

Primary Survey

AirwayAdvanced airway intubation is an independent risk factor of trauma-related mortality inpregnant trauma patients, with an RR of 6.0.1 Anatomic and physiologic changesmake the pregnant airway more challenging with a greater risk of airway managementproblems than nonpregnant patients, with up to 1 in 250 failed intubations found in asurgical setting.29 Pregnant women may have decreased ability to maintain a patentairway and sufficient ventilation, resulting in fetal distress. Maternal hyperventilationand alkalosis can reduce uterine blood flow via uterine vasoconstriction, also leadingto fetal distress.30 Airway edema, hyperemia, and landmark distortion can cause diffi-cult visualization during laryngoscopy.31

It is reasonable to have a lower threshold for advanced airway management giventhe low maternal oxygen reserve and exaggerated fetal response to maternal hypoxia.Preoxygenation and apneic oxygenation is critical to prevent maternal and fetal hyp-oxia throughout the procedure.32 Specific patient positioning beyond the sniffing po-sition is essential to maintain preload from left uterine displacement either manually(Fig. 2) or with a wedge under the right hip to 30� to reduce aortocaval compression,if GA is 20 weeks.33 Rapid sequence induction and anesthesia maintenance


Fig. 2. Manual left uterine displacement. (Courtesy of Christie Sun, MD, La Jolla, CA.)


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medications, such as volatile agents, depolarizing and nondepolarizing neuromus-cular blockers, fentanyl, and morphine, are safe to administer during pregnancy.33

Cricoid pressure should be used to decrease the risk of aspiration of gastric contents.Blind nasotracheal intubation is not advised because of engorgement and friability ofnasal mucosa from increased estrogen.The ED provider should have the following equipment on hand for intubation:20

� Adjunctive airway equipment, such as laryngeal mask airway andvideolaryngoscope

� Smaller size endotracheal tube (6.0–6.5) and stylets� Gum elastic bougie� Short laryngoscope handles

The initial ventilator settings should be similar to nonpregnant women with goals ofPCO2 of 28 to 35 mm Hg and should avoid respiratory alkalosis to prevent decrease inuteroplacental flow.20 Early nasogastric tube placement is warranted because of theincreased risk of gastroesophageal reflux.23,33

BreathingThe physiologic changes to the pulmonary system cause a significantly reduced oxy-gen reserve. This impairs compensation during respiratory compromise, and canresult in rapid development of maternal hypoxia.22 In trauma, supplemental O2 is indi-cated with pregnant women, with pulse oximetry goal of greater than 95% to maintainPaO2 greater than 70 mm Hg.20,27 Physiologic changes in pregnancy also cause alower PaCO2.

26 Therefore, PaCO2 of 35 to 40 mm Hg may indicate inadequate ventila-tion and impending respiratory decompensation in a pregnant woman. Additionally,the superior displacement of the diaphragm should be considered before needledecompression or tube or catheter thoracostomy.24

CirculationAccess with two large-bore intravenous (IV) lines should be placed to facilitate rapidcrystalloid infusion, volume expansion, and blood transfusions.27 Femoral and lowerextremity access should be avoided because of vascular congestion in the pelvisand lower extremities secondary to IVC compression by the uterus.22 Patients whoshow signs of hypovolemia, such as tachycardia, hypotension, or abnormal fetal hearttracings, should receive IV fluid resuscitation. If the patient is thought to be


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hemorrhaging or in hemorrhagic shock, blood products should be administeredinstead of crystalloid. Active hemorrhage should be controlled with tourniquet, directpressure, or pelvic binders. Massive transfusion protocol (MTP) with emergencyrelease O-negative blood should be activated in shock.27,34

Proper positioning, as discussed previously, with left uterine displacement (seeFig. 2) is critical for maternal hypotension in patients greater than 20 weeks GA toimprove maternal venous return and cardiac output.35 Decompression is accom-plished by either turning the patient into a left lateral position, placing a wedge underthe right hip, or manual displacement (Fig. 3).27

Secondary Survey

The secondary survey follows the primary survey, and consists of history, physical ex-amination, and ultrasound to identify maternal injuries. Concomitant evaluation of thefetal heart rate should be initiated. If the GA is greater than 23 weeks, external fetalmonitoring (EFM) should be used to assess fetal heart tones (FHTs) and uterine con-tractions. If the GA is less than 23 weeks, or if EFM is unavailable, M-mode on bedsideultrasound is used to ensure viability and fetal heart rate (normal range is 120–160beats per minute). Often abnormal fetal heart tracings or heart rates are the first signsof instability. For example, the first manifestation of maternal hypovolemic shock isoften uteroplacental insufficiency causing decreased variability and possible late de-celerations on FHT.27,36 This finding may be missed if there is delay in obtaining FHT.

HistoryHistory should be obtained regarding mechanism and severity of injury. Additionalquestions include presence of vaginal bleeding, leakage of fluid, contractions, andfetal movement especially if the fetus is viable and GA greater than 23 weeks. Further

Fig. 3. Proposed algorithm for management of trauma in patients greater than23 weeks GA. If less than 23 GA, consider focusing all resuscitation efforts on mother.ACLS, advanced cardiac life support; BP, blood pressure; CBC, complete blood count; CMP,complete metabolic panel; CT, computed tomography; CXR, chest radiograph; EFM, externalfetal monitoring; ETT, endotracheal tube; FAST, focused assessment with sonography fortrauma; FHR, fetal heart rate; FHT, fetal heart tole; GCS, glasgow coma score; HR, heartrate; IO, intra-osseous, KB, Kleihauer-Betke; LUD, lateral uterine displacement; NICU,neonatal intensive care unit; OB, obstetric; PXR, pelvic xray; Rh, rhesus factor; ROM, ruptureof membranes; TXA, tranexamic acid; XR, xray.



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obstetric history should be acquired including estimated delivery date, and complica-tions affecting current pregnancy, such as diagnosis of preeclampsia, gestational dia-betes, placenta previa, and oligohydramnios.

Physical examinationPhysical examination of the pregnant trauma patient is similar to the nonpregnant pa-tient and involves full exposure and thorough inspection and palpation of the entirebody.35 Key differences include physiologic vital sign alterations, abdominal examina-tion, gravid uterus, pelvic examination, and fetal evaluation.37 The abdominal exami-nation can be unreliable in the pregnant patient because of gravid uterus and maymask peritonitis or an acute abdomen.38 Abdominal contents are displaced superiorly,and penetrating injuries as high as the tip of the scapula posteriorly or the fourth inter-costal space anteriorly may involve intra-abdominal organs. Bruising or ecchymosis ofthe abdomen or persistent pain on examination may indicate visceral injury.27,39 Uter-ine tenderness is a sign of rupture or placental abruption.40

Pelvic examinationIn the pregnant patient with GA greater than 23 weeks, it is important to evaluate forvaginal bleeding or leakage of fluid. The differential for vaginal bleeding includesplacental previa, vasa previa, placental abruption, bloody show from cervical dilationwith preterm labor, or uterine rupture. External physical examination may suffice ifthere is no vaginal bleeding, leakage of fluid, uterine tenderness, or contractions pre-sent. If there is concern, sterile speculum and digital examination should be performedto identify cause of bleeding, presence of tissue, cervical dilation and effacement, andfetal station. Ultrasound should be performed before examination to rule-out placentaprevia. If there is concern for rupture of membranes, sterile speculum examinationshould be performed to assess for vaginal pooling of amniotic fluid or leakage of fluidfrom the cervical os.41 Defer digital examination if high concern for preterm rupture ofmembranes to reduce infection risk. Ideally these examinations are performed inconjunction with obstetrics.

Bedside ultrasoundBedside ultrasound is an important part of the secondary survey. Focused assess-ment with sonography for trauma (FAST) examination is pertinent in the hemodynam-ically unstable patient to exclude intra-abdominal hemorrhage. In three small studies,the sensitivity and specificity of FAST for detecting intra-abdominal hemorrhage weresimilar to nonpregnant patients at 80% to 85% and 98% to 100%, respectively.42–44

One study had a lower sensitivity of 61%.45 FAST should not be used to exclude intra-abdominal hemorrhage, but may save radiation and time in the setting of positive find-ings. If the patient is hemodynamically unstable and FAST positive, exploratory lapa-rotomy should be performed. If the patient is stable with a positive FAST, computedtomography (CT) scan may still be necessary to determine whether intra-abdominalinjury necessitates emergency surgery. Once the patient is stabilized, formal obstetricultrasound is obtained.

Laboratory Tests

In general, indicated laboratory tests are similar to the nonpregnant patient. Physio-logic changes in normal range for pregnant patients include leukocytosis, anemia,decreased creatinine, and increased clotting markers including fibrinogen and Ddimer.46 In addition to standard trauma laboratory studies, consider obtaining atype and screen, coagulation profile, fibrinogen, and Kleihauer-Betke (KB) test.


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Type and screenIt is important to determine Rhesus factor (Rh) status because Rh-negative patientsmay develop alloimmunization if the fetus is Rh positive, which may lead to hemolyticdisease of the fetus and newborn. This process can happen at 4 weeks inpregnancy.47

Kleihauer-BetkeFetal-maternal hemorrhage can occur in up to 30%of pregnant patients.48 The KB testuses a blood smear to quantify the amount of fetal hemoglobin in the maternal circu-lation. Because many fetal-maternal hemorrhage are subclinical, the American Col-lege of Obstetricians and Gynecologists (ACOG) guidelines advocate for KB testingin all pregnant trauma patients who are Rh negative because of concern for alloimmu-nization, which can happen at 4 weeks in pregnancy.47 The KB test helps to correctlydose Rh immunoglobulin.27,47,49,50

Imaging Studies

Radiology plays an important role in trauma resuscitations, and it is no different in thepregnant trauma patient. Practitioners may grapple with this because of the perceivedfetal risk of teratogenicity and carcinogenesis. In general, imaging should be per-formed as clinically indicated regardless of pregnancy status, including studies withionizing radiation, especially in settings of maternal instability.Per ACOG, Society of Obstetricians and Gynecologists of Canada, and Eastern As-

sociation of the Surgery of Trauma (EAST), radiation less than 5 rad (50 mGy) poseslittle to no risk of teratogenicity or fetal loss. Imaging is generally well below thisthreshold.27,49,51,52 The fetus is at highest risk of teratogenicity at less than 12weeks.51

If necessary radiation exceeds 5 rad, discussing the risks and benefits of imagingstudies and shared decision making with the patient should be done. Conflictingstudies exist whether or not fetal exposure to ionized radiation is associated withcarcinogenesis.52–56

Table 4 lists fetal radiation dose per imaging study. Strategies should be used tolimit the amount of fetal radiation exposure when feasible, such as using lead protec-tion over the gravid abdomen, selecting alternative protocols, and imaging with lessradiation when it is feasible without compromising resuscitation.

Table 4Fetal radiation doses of common trauma imaging

Imaging Study Fetal Dose (mGy)

Head or neck CT 0.001–0.01

Radiography of any extremity <0.001

Chest radiography (two views) 0.0005–0.01

Abdominal/pelvic radiography 0.1–3.0

Chest CT 0.01–0.66

Lumbar spine radiography 1.0–10

Abdominal CT 1.3–35

Pelvic CT 10–50

Abbreviation: CT, computed tomography.Adapted from Committee on Obstetric Practice. Committee opinion no. 723: guidelines for diag-

nostic imaging during pregnancy and lactation. Obstet Gynecol 2017;130(4):e210–6.



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UltrasoundUltrasound is generally safe and is easily repeated without harm if the clinical situationrequires it. Although B-mode and M-mode are generally safe, there is a theoretic riskof increasing temperature with higher intensity ultrasound transduction throughDoppler, use of which should be minimized or reserved only for obstetricultrasounds.51,57

RadiographsRadiographs of the chest, extremities, and spine generally expose the fetus to lowlevels of radiation and should be performed as indicated. Pelvic radiograph has ahigher dose of radiation (up to 0.3 rad or 3 mGy). The treating physician may considerforegoing pelvic radiograph if abdominal and pelvic CT or MRI will be obtained.51 Ra-diation exposure during image acquisition is reduced through such techniques as fluo-roscopy, use of mini C-arm, strategic shielding of the fetus, and real-timedosimetry.58,59

Computed tomographyCT scans of the head, neck, and chest expose the fetus to low to moderate levels ofradiation. CT of the abdomen and pelvis has a higher dose of radiation (up to 5 rad or50 mGy) and but should be obtained if there is concern for intra-abdominal injury. Ul-timately, given the potential risk of tetratogenesis and carcinogenesis, albeit low, ra-diation exposure should be limited to as low as reasonably possible, withoutcompromising maternal resuscitation.27,49,51 Iodinated contrast is generally safe inpregnancy and is considered a category B drug by the Food and Drug Administration(FDA).51,60

Magnetic resonance imagingACOG recommends no special considerations or restrictions for MRI in pregnant pa-tients, whereas the 2010 EAST guidelines do not recommend MRI in the first trimesterof pregnancy.49,51 Gadolinium is no longer recommended in pregnant patientsbecause there is increased risk in inflammatory skin conditions, stillbirth, and neonataldeath.51,61 In the setting of a stable patient with a low suspicion of injury, MRI may be areasonable alternative to CT scan.51,60 MRI may also be a superior method of imagingfor follow-up studies to avoid additional radiation exposure. However, MRI should notbe the initial diagnostic imaging choice if there is high suspicion for injury orinstability.60

Treatment of Shock

Critical interventions, such as intubation, chest tube thoracostomy, venous access,and IV fluid administration, should all be performed as indicated with appropriatemodifications for the pregnant patient. Shock, usually from life-threatening hemor-rhage, is critically important to recognize and treat. The end goal should be balancedresuscitation, because overresuscitation with fluids can lead to pulmonary edema andworsened hemorrhage.62,63 However, permissive hypotension as advocated by cur-rent trauma guidelines may be detrimental to fetal well-being, therefore resuscitationstrategies should include real-time fetal heart tracing in reassessments and deter-mining next steps in resuscitation.27 Abnormal FHT can be the first sign of significantmaternal hemorrhage.

Hemorrhage controlControlling hemorrhage is an important part of managing shock. Tourniquets shouldbe placed for exsanguinating extremities, pelvic binders for open book pelvic


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fractures, and pressure should be placed on bleeding lacerations. If there are signs ofintra-abdominal fluid on FAST in the setting of shock, emergent surgical interventionmay be necessary.49

Massive transfusion protocolBlood and blood products should be administered to all pregnant patients with hem-orrhage and hemodynamic instability or signs of fetal distress. O-negative bloodshould be used as emergency release if cross-matched blood is not available.27

MTP should be activated if necessary as per trauma guidelines in a 1:1:1 ratio ofpacked red blood cells to fresh frozen plasma (FFP) to platelets.64 Most guidelineson obstetric hemorrhage are based on postpartum hemorrhage and also recommendsimilar 1:1:1 MTPs.65–67

CoagulopathyFFP, platelets, and cryoprecipitate and fibrinogen are administered if there are signs ofcoagulopathy. If elevated international normalized ratio is persistent, it may be reason-able to give additional FFP (2–4 units) with a goal international normalized ratio lessthan 1.5.67 FFP has an FDA category C rating. Prothrombin complex concentrate isalso used to reverse coagulopathy.68 Platelets may be transfused for goal plateletcount greater than 50 � 109/L.63,68 If fibrinogen is less than 2 g/L in the setting oflife-threatening hemorrhage, fibrinogen (1–2 g) or cryoprecipitate (10 units) may begiven.63,66,68 No data exist on the safety of prothrombin complex concentrate, fibrin-ogen, or cryoprecipitate in pregnancy, but these products should be administered iflife-threatening hemorrhage is present with evidence of coagulopathy.

Tranexamic acidThere are no studies evaluating tranexamic acid in the pregnant trauma patient, but ithas been shown to reduce mortality in nonpregnant trauma and postpartum hemor-rhage patients without increased incidence of venous thromboembolic events.69,70

Therefore, it is reasonable to give tranexamic acid in the pregnant trauma patientwith significant hemorrhage. Tranexamic acid is a category B medication per theFDA.

VasopressorsIn general, traumatic patients are hypotensive because of hypovolemia and hemor-rhage and should be treated with volume rather than vasopressors initially. Vasopres-sors may also cause uteroplacental insufficiency because of effect on uterine tone andvasculature.27 During cardiac arrest vasopressors should be used per advanced car-diac life support (ACLS) guidelines.62,71 In specific situations, such as peri-intubationhypotension, it may be reasonable to use phenylephrine for vasoconstriction becausethis has been shown to be safe in pregnant patients experiencing hypotension fromspinal epidural anesthesia.72

Other Interventions

Tocolytics/b-methasoneIf the fetus is viable with GA greater than 23 weeks but less than 34 weeks, and thepatient is in early preterm labor with cervical change, consider using tocolytics. Con-traindications to tocolysis in the trauma patient include nonreassuring FHT and hemo-dynamically instability. Options include betamimetics (terbutaline), magnesiumsulfate, or calcium antagonist (nifedipine).73 If GA is greater than 24 weeks but lessthan 37 weeks, also consider the use of b-methasone to help with fetal lungmaturity.74,75



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RhogamProphylactic Rho(D) immunoglobulin (Rhogam) should be given to all Rh-negativepregnant trauma patients within 72 hours.27,47,49 One dose (300 mg) covers 30 mLof fetal blood.27,47,76 If KB test estimates fetal blood within maternal to be greaterthan 30 mL, additional Rhogam doses should be given.27

Traumatic Arrest

In the event of traumatic arrest, ACLS should be initiated with primary focus onsecuring the airway, administering adequate oxygenation and ventilation, obtainingsufficient IV access with large-bore catheters above the diaphragm, and providing cir-culation with chest compressions and left uterine displacement, as well as balancedresuscitation with blood products.62 If available, trauma, obstetric, anesthesia, andneonatal teams should arrive immediately to the bedside to aid in resuscitation.77

Equipment for perimortem cesarean delivery (PMCD), thoracotomy, and other resus-citative interventions should immediately be brought to the bedside as indicated.The focus of resuscitation should be on identifying and treating the underlying cause

of traumatic arrest, such as hypovolemia or hemorrhage; tension pneumothorax; car-diac tamponade; hypoxia; or medical etiologies that may have occurred, such asseizure. Indications for thoracotomy should remain similar to the nonpregnant patientgiven the paucity of data in the pregnant patient.62,78 Defibrillation, epinephrine, andother ACLS drugs should be administered without altering the dose, timing, orjoules.71,77,79

Perimortem cesarean deliveryIf maternal resuscitation is unsuccessful, the American Heart Association, ACOG, andEAST guidelines recommend emergency PMCD.27,49,77,79,80 Indications for this pro-cedure include79,81–84:

� Unsuccessful maternal resuscitation after 4 minutes� GA at or greater than 23 weeks or fundal height above umbilicus

A case series by Katz and colleagues81 identified 38 PMCDs in the setting ofmaternal cardiac arrest, eight involving trauma. Thirty of the 38 procedures resultedin the delivery of a viable infant, with 7 out of 38 involving fetus delivery greater than15 minutes frommaternal cardiac arrest. Twelve out of 20 cardiac arrests achieved re-turn of spontaneous circulation after PMCD, although none involved traumaticarrest.81

FETAL EVALUATION AND RESUSCITATION

It is important to evaluate fetal well-being in parallel with maternal resuscitation, butnot at the expense of maternal resuscitation. Strategies to evaluate the fetus includeultrasound, FHT, tocometry, and early involvement of obstetrics. If the fetus is previ-able, interventions are limited and resuscitation should focus on themother.27 In casesof viability, it is important to quickly assess FHTs for signs of distress. Emergency de-livery or intervention is indicated in the setting of such injuries as placental abruption,uterine rupture, and maternal hemorrhage.27 Fetal mortality in the setting of trauma is61% in major trauma, and between 1.3% and 19% in all trauma based on other cohortstudies.39,85–87

Ultrasound

Early involvement of obstetrics can allow for ultrasound evaluation beyond beside ul-trasound to examine the fetus, placenta, amniotic fluid, and fetal position.27 Signs of


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placental abruption may be identified through ultrasound in the hands of an experi-enced user, although ultrasound is not sensitive for this diagnosis.6,42,88,89

Fetal Heart Monitoring and Tocometry

It is important to obtain FHTs and tocometry early and continuously in pregnanttrauma patients. All pregnant trauma patients with GA 20 weeks should have minimumof 6 hours EFM observation, and longer if clinically warranted.49 This provides surro-gate information for fetal well-being, fetal acid-base status, and fetal perfusion.90

Maternal hemorrhage, fetal hemorrhage, fetal hypoxia, placental abruption, and uter-ine rupture should be considered if FHTs shows signs of fetal distress.27,87 In thesetting of extreme fetal distress, urgent or emergent cesarean should be consideredin consultation with neonatology and obstetrics.27,36 Interventions for nonreassuringFHTs include continuing maternal resuscitation, supplemental oxygen, and left lateraldecubitus positioning.27 Tocometry is the external monitoring of maternal uterine con-tractions and should take place concurrently with fetal heart monitoring with GAgreater than 23 weeks. In the case of contractions causing intense pain and regularcontractions less than 10 minutes apart, consider placental abruption or pretermlabor.6,27

Duration of External Fetal Monitoring

The duration of fetal monitoring is a topic of controversy. Studies have failed toobserve reliable predictable factors for fetal demise, preterm delivery, or adverseoutcome.6,91 EAST guidelines suggest a minimum of 6 hours, ACOG guidelines donot give specific time but suggest a minimum of 6 hours.49,80 Society of Obstetriciansand Gynecologists of Canada recommends 4 hours if normal FHT and physical exam-ination, but prolonged monitoring (24 hours) if there are any of the following present:uterine or abdominal tenderness, vaginal bleeding, contraction frequency of morethan once per 10 minutes, rupture of membranes, nonreassuring FHTs, serum fibrin-ogen less than 200 g/L, and high-risk mechanism.27

Indications for Emergency Cesarean Section

Indications for emergency cesarean section in the operating room are determined withthe consulting obstetrician. Obstetrics should immediately be consulted if there aresigns of maternal instability, uteroplacental compromise, and decreased fetal well-be-ing.27,36 During traumatic cardiac arrest, PMCD should be initiated at 4 minutes andperformed at the bedside without delay.

OBSTETRIC PATHOLOGYPlacental Abruption

Placental abruption is the leading cause of fetal death following blunt trauma.49 Astudy involving 372 pregnant trauma patients (84% blunt, 16% penetrating) in the thirdtrimester showed placental abruption as the most common complication at 3.5% with54% mortality. Other studies have indicated a placental abruption rate between 5%and 50%.89 The time course of presentation is usually delayed between 2 and 6 hoursfrom initial trauma, up to 24 hours. Concerning symptoms include nonreassuringFHTs, vaginal bleeding, uterine tenderness, and contractions. Severe placental abrup-tion can result in hemorrhagic shock and signs of disseminated intravascular coagu-lation.49 Although the diagnosis is primarily clinical, CT scan and ultrasound may aid indecision making.6,27,42,88,89,92–94 Immediate obstetric consultation should take place ifthere are any signs of placental abruption.



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Uterine Injury

Uterine injuries in trauma include uterine contractions, serosal hemorrhage, abrasions,and complete uterine rupture.27 Uterine contractions are the most common complica-tion associated with maternal trauma.18 Uterine rupture is rare with an incidence ofapproximately 0.7% and should be suspected in the setting of direct abdominalinjury.27,58,95

Signs or symptoms of severe uterine injury and uterine rupture include peritonealabdominal examination, maternal hemodynamic instability, irregular uterine contrac-tions, palpable fetal parts, and sudden abnormal fetal heart rate pattern.27 A FAST ul-trasound examination will likely show free fluid in the abdomen in uterine rupture.58

Unfortunately, fetal mortality with traumatic uterine rupture is almost universal. Earlyrecognition is key with obstetric consultation for laparotomy to control hemorrhage,repair the uterus, and evaluate for fetal viability.27

Preterm Labor

Evaluation for preterm labor should be done in every injured pregnant patient. There isan associated higher risk of preterm delivery after trauma (RR, 2), increasing with injuryseverity and earlier GA.96 Placental abruption may result in preterm labor in up to 20%of cases.97 EFM should be used to monitor for any contractions, frequency, and reg-ularity of contractions. If preterm labor is suspected and the patient is stable, transfershould be initiated to obstetric services is appropriate for further evaluation.

SPECIFIC MATERNAL INJURIESMotor Vehicle Accidents

The overall incidence of MVAs during pregnancy has been estimated at 207 cases per100,000 live births, and is the most common cause of traumatic injury.85 The presenceof illicit drugs or alcohol is significant with pregnancy-related traumas (19.6% and12.9%, respectively), and is found present in up to 45% of pregnant women involvedin MVAs.4 Pregnant women involved in MVAs are also unrestrained up to 79% of thetime. Not wearing a seatbelt is associated with more severe injuries, higher frequencyof surgical interventions, and adverse fetal outcome.98 Seatbelt placement also is anissue with nearly 50% of fetal losses associated with improper strap placement.99

Seatbelts should be worn below the abdomen, touching the against thighs.99 Airbagdeployment has not been found to significantly increase likelihood of placental abrup-tion or fetal loss.13

Up to 89% of pregnant women who are involved in MVAs can present with maternalor fetal complications requiring medical care, with most admissions occurring at greaterthan 20 weeks GA.100 Among severely injured women in MVAs, placental abruption canoccur in up to 40% of cases with maternal mortality rate of 13.7%.13,86 However, evennonseverely injured pregnant women have an increased risk of preterm labor, placentalabruption, and cesarean delivery.7 Even minor accidents can create enough force todistort the uterine wall causing the placenta to shear leading to abruption.6 The fetalmortality rate secondary to MVAs overall has been found to be 10.7%,13 with an esti-mated 1300 to 3900 fetal losses per year in the United States secondary to MVAs.101

Falls

Falls are the second most common cause of blunt trauma in pregnant women, with anincidence of 48.9 cases per 100,000 live births.102 Approximately one in four pregnantwomen fall at least once in pregnancy.15 Falls are most common in the second andthird trimesters,102 likely caused by anatomic changes occurring in pregnancy leading


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to a predisposition to falls.103 Most falls occur from standing height and indoors, with39% involving stairs.15,102 Adverse events associated with falling include increase inrates of preterm labor (RR, 4.4), placental abruption (RR, 8), fetal distress (RR, 2.1),fetal hypoxia (RR, 2.9), and stillbirth (RR, 2).102

Penetrating Injuries

Penetrating trauma including GSWs in pregnancy is uncommon and incidence is esti-mated at 3.3 cases per 100,000 live births.14,16,17,104 Maternal mortality is not signifi-cantly different in penetrating trauma mechanisms as compared with blunt; however,there are significant increases in maternal morbidity (66% vs 10%, respectively).14

Common maternal complications include uterine injury and ileus.14 Direct fetal injuryand mortality in the third trimester is more common with penetrating trauma especiallyGSWs (up to 70%).13,34,105

Domestic Violence

DV or intimate partner violence is the most common form of intentional trauma, with upto 20.1% of women reporting physical or sexual abuse while pregnant.106,107 The inci-dence of DV is estimated to be at 8307 cases per 100,000 live births.108 Most often thedomestic partner is identified as the aggressor in DV cases.107 Risk factors for DVinclude substance abuse (maternal or partner), unintended pregnancy, history of DVbefore pregnancy, and unmarried status.109,110 Adverse outcomes associated withDV include increased risk for spontaneous abortion and preterm birth (1.7), andincreased risk for low birth weight, fetal distress, and fetal death (RR, 2).109 The riskof fetal death has been found to be directly and significantly correlated to severityof maternal injuries.111 At times, victims may present with a plausible story of injuryand therefore DV may be overlooked, making it imperative to screen all pregnanttrauma patients.

Burns

Burn injuries in pregnancy are rare, estimated at 0.17 cases per 100,000 live births.112

Multiple studies have shown the overall maternal and fetal mortality to be high (up to66%) regardless of total body surface area involved or GA.113,114 Maternal and fetalmortality rates approach 100% if total body surface area exceeds 55%.112,113,115

Therefore, urgent obstetric consultation for cesarean delivery is recommended incases with total body surface area burn greater than 55%.115 Burns during the firsttrimester have also been associated with spontaneous abortions,116 which typicallyoccur within 10 days after the burn.117 Inhalation injury may also occur with burnsmaking an already difficult airway even more challenging.58 Co-oximetry and cyanidetoxicity should also be considered because carbon monoxide and cyanide can trans-fer to the fetus.58,115,116 Treatment is similar to nonpregnant patients with oxygen andhydrocobalamine.58,112,115

DISPOSITION

After stabilization, disposition from the ED is generally to labor and delivery forextended monitoring. If labor and delivery is not present at the hospital of the treatingED, transfer for higher level of care is warranted especially if there are signs of fetaldistress or abnormalities on maternal physical examination.Stable patients may be discharged following an appropriate period of observation.

This includes at least 4 to 6 hours of observation for low-risk patients with normalphysical examination and reassuring FHT, and at least 24 hours for high-risk patients



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with abnormal physical examination, frequent contractions, or any signs of nonreas-suring FHT. Patient should have close obstetric follow-up and strict return precautionsincluding decreased fetal movement, vaginal bleeding, contractions, rupture of mem-branes, and severe pain.27

SUMMARY

The resuscitation and management of pregnant trauma patients is difficult becausethe provider must consider maternal physiologic changes during pregnancy; fetalwell-being; and unique pathologies, such as placental abruption and preterm labor.Prioritization of maternal resuscitation is critical to ensure optimal outcome for themother and fetus. Trauma in pregnancy, a rare event, also requires close communica-tion and teamwork with multiple specialties.

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Trauma in Pregnancy · 2020. 5. 26. · Trauma in Pregnancy Jeffrey Sakamoto, MDa, Collin Michels,...

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